gap cover supplementary form - discovery

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Discovery Supplementary Gap Cover is an insurance product. This is not a medical scheme and the cover is not the same as that of a medical scheme. This policy is not a substitute for a medical scheme membership. Discovery Supplementary Gap Cover is a long-term insurance policy, underwritten by Discovery Life Ltd, a registered long-term insurer, and an authorised financial services and registered credit provider, NCR Reg No. NCRCP3555.

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Discovery Supplementary Gap Cover application form 2019

Contact us

Tel: 0860 99 88 77, PO Box 784262, Sandton, 2146, www.discovery.co.za

Who we are

Discovery Supplementary Gap Cover is a long-term insurance product, underwritten by Discovery Life and is a separate product that is not conditional on the purchase of Discovery Gap Cover. Discovery Supplementary Gap Cover is only available to members of Discovery Health Medical Scheme (referred to as ‘the Scheme’ throughout this document), excluding Discovery Health Medical Scheme KeyCare plans. The policy for which you are applying is not a medical scheme and the cover is not the same as that of a medical scheme. This policy is not a substitute for medical scheme membership. This application form also contains some of the terms and conditions for the policy. Please ensure that you have read and understood this application form. Details of your cover are set out in the policy guide and policy schedule, which together with this application, form the basis of your policy contract.

What you are applying for

• You are applying for Discovery Supplementary Gap Cover.

• Only you and your Spouse can be covered under this policy.

What you must do

• Complete the form in black ink. Please print clearly.

• Read and understand the rules of the policies (Annexure 1).

• Please ensure the main member of the Scheme signs this form, and initials any changes, where applicable.

• Email the completed and signed application form to [email protected] or fax the completed and signed application form to 011 539 3000.

• Please note that this application form is only valid for 90 days from date of signing it.

Once we receive your completed application form, here is what will happen:

• We will process your application and send you (the main applicant) and your financial adviser (if applicable), a letter notifying you if it has been accepted,or rejected;

• If any details are missing from this application or if we need more information, we will contact you and/or your financial adviser; or

• If we accept your application form, but the terms of your acceptance differ from the standard terms of the policy based on your underwriting results, thiswill be indicated and you will be advised of any additional terms and conditions applicable to your policy. We will send you a letter which you will need to sign and send back to us, accepting the revised terms.

• Upon activation of your policy, you and your financial adviser (if applicable) will receive an SMS or an email to notify you that your application is completeand when your policy starts. You will also receive a policy schedule and policy guide. Please read all information we send to you so that you are familiarwith the terms of your cover.

When you sign this application, you confirm that you have read and understood the terms and conditions for cover and you agree to them.

1. About yourself, the main applicant (you are also the main member on the Scheme)

Please note: Only the main member of the Scheme can apply for this policy. You are completing this application for yourself and on behalf of your spouse (if applicable).

Are you an existing Scheme member? ☐ Yes ☐ No

If you’ve answered “No”, you must apply to become a member of the Scheme. Please complete a separate Scheme application form and submit it together with this Gap Cover application. We will only consider this application once your Scheme application has been approved.

Your Scheme membership number (if applicable):

Title Initials Surname

First name(s) (as per identity document)

Email

Cellphone

ID or passport number (please

Gender ☐ M ☐ F Date of birth Y Y Y Y M M D D

When do you want cover to start? Y Y Y Y M M D D

Please note:

• Unless you have specified a cover start date, the policy start date will default to the 1st of the month following the finalisation of your application. If you would like to use different contact details, you can update your details on “Update Your Details” on the website, once you have completed yourapplication.

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2. Replacement of an existing policy

Important note: Replacement of any insurance may be to your disadvantage

If you are intending to take out any of these policies to replace an existing policy you have with any other insurer, please speak to your financial adviser to understand if and how this may be a disadvantage to you.

Is this application to replace the whole or any part of an existing insurance with any insurer (whether replacement is to occur immediately or to replace

insurance cover discontinued within the past six months or to be discontinued within the next six months)? ☐ Yes ☐ No

3. Your financial adviser’s details (to be completed by your financial adviser, where applicable)

Financial adviser’s name Code

Intermediary house Code

Financial adviser’s telephone number (W)

Cellphone

Email

Financial adviser’s signature

By signing this you acknowledge that you have read, understood and completed the declaration below.

I declare that: (mark relevant tick boxes)

3.1. I am an accredited financial adviser and licensed by the FSB to sell long-term insurance in terms of the FAIS Act at the date of signing this application form.

3.2. I am appointed by the client to provide advice about this application. 3.3. I have a valid contract with Discovery Life. 3.4. I am responsible for providing the applicant with:

• my name, physical address, postal address and telephone number;

• full details on the commission payable to me by Discovery Life;

• Impartial advice that is in his or her best interest.

3.5. I am accountable for any advice given to the member about the completion of this application form and joining Discovery Supplementary Gap Cover. 3.6. I have consent from the member to service their Discovery Supplementary Gap Cover policy. 3.7. I have requested and recorded the client’s response to the question (refer to Section 2) with regard to replacement of their policy and that the client is

fully aware of the possible negative consequences of the replacement of an insurance policy. 3.8. I further declare that, irrespective of the client’s response to the question in Section 2, that I have explained the following to the client:

• The meaning of a replacement;

• That a replacement is potentially prejudicial;

• The levying/deduction of a termination charge;

• That where a replacement is considered, the client is legally entitled to comprehensive information regarding the consequences of replacement;

• Where the client answered “Yes”, I have discussed and completed the Replacement Policy Advice Record and/or Replacement Comparison.

4. Your banking details

Please provide us with your banking details from where we will collect premiums and into which we will pay claims and the Annual Payback, where applicable. We cannot accept credit card account details and only South African banking details are accepted. 4.1. Paying your premiums

If you will be paying your premium from your own personal bank account, please complete this section.

Please note: If you provide the same banking details as for the collection of your Scheme contributions, your Scheme and Discovery Gap Cover premium will be collected as a single debit

Bank name

Branch name Branch code

Account number Type of account ☐ Cheque ☐ Savings

Account holder

Your monthly premium will be collected on the same day as your medical scheme contribution’s debit order date. If your policy is not activated prior to the debit order submission, the first outstanding premium will be included with the following month’s debit order. Should the payment day fall on a Sunday or a recognised South African public holiday, the payment day will automatically be on the next business day.

Account holder’s signature

Signature of main applicant

4.2. Your claims’ refunds

Can we use the same account we deduct premiums from, to pay your claims and the Annual Payback into, where applicable? ☐ Yes ☐ No

If you’ve answered “No”, please give us the details you would like to use.

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Your banking details (continued)Bank name

Branch name Branch code

Account number Type of account ☐ Cheque ☐ Savings

Account holder

Please note: If you are using someone else’s bank account, the account holder must sign below to confirm and consent to this.

Account holder’s signature


5. Your health questions

As the main applicant, you are completing these questions on behalf of your spouse (if applicable), and you confirm that you have the necessary knowledge and authority to fully do so. It remains your responsibility to answer all of these questions accurately and honestly. By not giving us all the relevant, true and complete information, we may enforce the terms of point 7.3.1 “Disclosure of relevant information”, which could mean that the policy or benefits will be cancelled.

What you need to do:

Please complete this section for yourself and for your spouse (if applicable) on the Scheme.

5.1. Have you or your spouse experienced, received medical advice, been diagnosed, received care or been treated for any of the following symptoms, conditions or disorders?

5.1.1. Diabetes Mellitus; or 5.1.2. Any organ transplant; or 5.1.3. Drug or alcohol abuse; or 5.1.4. Unintentional weight loss of more than 5kg in the last year?

Main applicant

☐ Yes ☐ No

Spouse

☐ Yes ☐ No

5.2. Do you or your spouse participate in any hazardous activities? Please refer to Annexure 2 for a complete list of hazardous activities.

Main applicant

☐ Yes ☐ No

Spouse

☐ Yes ☐ No

Main applicant

☐ Yes ☐ No

Spouse

☐ Yes ☐ No

5.3. Have you or your spouse applied for an insurance policy in the past and:

5.3.1. Was refused cover on that policy for any reason; or

5.3.2. Was offered cover on that policy, but on special terms such as loadings or exclusions; or

5.3.3. Was accepted and paid out for injury, sickness, dread disease or disability?

5.4. Are you aware of any other circumstances or potentially risky or illegal activities in which you and/or your spouse

partake, e.g. substance abuse or other unlawful activities, travelling to a country at war, search and rescue efforts etc.? Main applicant

☐ Yes ☐ No

Spouse

☐ Yes ☐ No

5.5. Do you or your spouse have two or more immediate family members been diagnosed with the same type of cancer before the age of 50?

Main applicant

☐ Yes ☐ No

Spouse

☐ Yes ☐ No

5.6. Have you or your spouse had some type of genetic testing, tumour markers or any other special investigations indicating a higher risk for a familial cancer syndrome for example familial multiple adenomatous polyposis, hereditary breast and ovarian cancer, or multiple endocrine neoplasia?

Main applicant

☐ Yes ☐ No

Spouse

☐ Yes ☐ No

5.7. Are you or your spouse HIV positive or have you or your spouse been diagnosed with AIDS? Main applicant

☐ Yes ☐ No

Spouse

☐ Yes ☐ No

5.8. Have you or your spouse smoked or used tobacco products or e-cigarettes in the last 12 months? If you or your spouse answers “Yes”, smoker rates will apply to the premium for the person who answered “Yes”.

Main applicant

☐ Yes ☐ No

Spouse

☐ Yes ☐ No

5.9. Have you or your spouse experienced, received medical advice, been diagnosed, received care or been treated for any of the following symptoms, conditions or disorders?

5.9.1. Heart and / or circulation conditions

List of medical conditions: Heart Failure, angina, ischemic heart disease, heart attack, coronary artery stent or coronary artery bypass graft, heart valve replacement or other cardiac surgery, heart valve abnormalities, cardiomyopathy, uncorrected congenital heart disease for example uncorrected septal defects, coarctation of the aorta, life threatening arrhythmia, pacemaker or implantable cardioverter defibrillators insertion, myocarditis or pericarditis with persisting symptoms, uncontrolled hypertension or uncontrolled familial high cholesterol, aneurysms or peripheral vascular disease, abnormal investigation of the heart for example abnormal ECG or echocardiography, angiogram.

Main applicant Spouse

☐ Yes ☐ No ☐ Yes ☐ No

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Your health questions (continued) 5.9.2. Metabolic or endocrine

disorders List of medical conditions: Cushing’s syndrome, Addison’s syndrome, uncorrected thyroid disorders.



5.9.3. Breathing and respiratory conditions

List of medical conditions: Emphysema or chronic obstructive pulmonary disease, pulmonary hypertension, occupational lung diseases, chronic bronchitis, ongoing shortness of breath or difficulty in breathing, cystic fibrosis, bronchiectasis, interstitial lung disease or lung fibrosis, tuberculosis, abnormal investigations such as abnormal lung function tests, scans or x rays.



5.9.4. Abdominal conditions List of medical conditions: Chronic liver disease with fibrosis or cirrhosis, Liver failure, Sclerosing cholangitis, chronic inflammatory bowel diseases (ulcerative colitis, Crohn’s disease), chronic hepatitis, pancreatitis, enlarged spleen, portal hypertension, abnormal investigations such as abnormal gastroscopy, colonoscopy, biopsy or scan.



5.9.5. Kidney or urinary conditions List of medical conditions: Renal (Kidney) failure, polycystic kidneys, glomerulonephritis, chronic pyelonephritis.



5.9.6. Connective tissue, joints and skin disorders

List of medical conditions: Systemic lupus erythematosus, rheumatoid arthritis, scleroderma, progressive systemic sclerosis, Sarcoidosis, Polymyositis, Wegener’s granulomatosis, Dermatomyositis, Giant cell arteritis, Polyarteritis nodosa, Sjögren's syndrome, Marfan syndrome, Ehlers-Danlos syndrome, Pseudoxanthoma elasticum, Ankylosing Spondylitis, Psoriasis or psoriatic arthritis.



5.9.7. Brain and nerve or nervous system conditions

List of medical conditions: Stroke or transient ischemic attack, Optic neuritis, Multiple sclerosis, Parkinson’s disease, Motor neuron disease, Myasthenia gravis, Alzheimer’s disease and dementia, Myotonia, Muscular dystrophies, Loss of hearing, Loss of speech, Loss of vision (not related to wearing of glasses), Uncontrolled epilepsy, Abnormal nervous system investigation for example CAT scan, MRI, EEG etc.



5.9.8. Musculoskeletal disorders List of medical conditions: Quadriplegia, Paraplegia, Ongoing neck or back pain, disc prolapse, spondylosis, spondylolisthesis, spinal stenosis, nerve root compression, Osteoporosis, Osteoarthritis, Any spinal surgery, Previous joint replacements.



5.9.9. Mental health and emotional disorders

List of medical conditions: Schizophrenia, bipolar mood disorder, major depressive disorder, post-traumatic stress disorder, Eating disorders e.g. anorexia nervosa, Any psychiatric condition resulting in being off work for more than two weeks or hospitalization for one week or more, Any suicide attempt.



5.9.10. Cancer List of medical conditions: Any cancer including in situ cancer, leukemia and lymphoma or blood related cancer, any brain and spinal cord tumours.



5.9.11. Blood Conditions List of medical conditions: Abnormal clotting, deep vein thrombosis, pulmonary embolism, abnormal bleeding (hemophilia), low platelet count (thrombocytopaenia)/ Idiopathic Thrombocytopenic purpura.



6. Acceptance of application

All information is true and correct, and I accept the terms and conditions outlined in Annexure 1. I also confirm my understanding that the answers provided to the health and pre-existing condition questions in Section 5 may have an impact on whether my application is accepted or not.

Signed at (town or city) on Y Y Y Y M M D D


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Annexure 1 – Terms and conditions

7. General terms and conditions

7.1. Key terms used

7.1.1. “Application” is this form you complete and sign. Together with the policy schedule and policy guide, it forms the basis of the policy contract. 7.1.2. “Claimant” means any person making a claim for a benefit under the policy. 7.1.3. “Discovery Group” means Discovery Holdings Limited (registration number 1999/007789/06), a public company incorporated in South Africa the

shares of which are listed on the JSE Limited, and all of its affiliates and subsidiaries from time to time including but not limited to Discovery Life Limited (registration number 1966/003901/06), Discovery Life Investment Services (Proprietary) Limited (registration number 2007/005969/07), Discovery Vitality (Proprietary) Limited (registration number 1999/007736/07), Discovery Health (Proprietary) Limited (registration number 1997/013480/07), Discovery Insure Limited (registration number 2009/01182/06) and Discovery Life Collective Investments (Proprietary) Limited (registration number 2007/008998/07). Subsidiaries within the Discovery Group are authorised financial services providers.

7.1.4. “Lives assured” means you or your spouse who are covered as indicated on your policy schedule. 7.1.5. “Main applicant” is the main member on the Scheme and the person completing this application. 7.1.6. “Non-assured entity” means any person indicated in your policy schedule that is not covered or is not entitled to any benefits. 7.1.7. “Policy” refers to the Discovery Supplementary Gap Cover policy and which policy is made up of this application form, the policy schedule and policy

guide for Discovery Supplementary Gap Cover any changes that you might make thereon. 7.1.8. “Policy schedule” includes the summary of the policy, which we send to you after we have accepted your application for cover, or any changes that are

made thereto. 7.1.9. “Policyholder” means the natural person named as such in the policy schedule. 7.1.10. “Scheme” means Discovery Health Medical Scheme. 7.1.11. “Spouse” means a person registered as such on your Scheme. 7.1.12. “We”, “us” and “our” refers to:

7.1.12.1. Discovery Life Limited (registration number 1966/003901/06), a public company with limited liability, registered under the company laws of the Republic of South Africa; and / or

7.1.12.2. Discovery Health (Proprietary) Limited (registration number 1997/013480/07) a private company registered under the company laws of the Republic of South Africa; and Administrator of your policy.

7.1.12.3. These entities are authorised financial services providers.

7.1.13. “You” and “your” refers to you as the policyholder and includes your spouse. 7.1.14. “Your Personal Information” refers to personal information about you, your spouse, your beneficiaries, and your employees (as relevant). It includes

information about health, financial status, gender, age, contact numbers and addresses.

7.2. Conditions of the policies

7.2.1. It is a condition of the policy that you as policyholder and the lives to be assured must be members of the Scheme. Termination of your membership from the Scheme will result in the automatic termination of the policy you are applying for under this application.

7.2.1.1. Membership of the KeyCare Plan or its equivalents does not qualify you for application for the policy. 7.2.1.2. Any changes that you make to your medical scheme plan and / or Vitality Status may result in a change to the premiums and/or benefits of your

policy. We will affect the change to the policy and will notify you of the changes made in such circumstances.

7.3. Authority

7.3.1. Disclosure of relevant information You warrant and declare that all the information provided by you in this application form is true and correct. You further warrant that you will continue to disclose to us any material information until we have accepted risk or until the policy commences, whichever day occurs last. You know and understand that a breach of any of the warranties you have given herein may result in us voiding the policy from inception, or us rectifying the terms thereof and contributions paid being used to offset expenses incurred by us.

7.3.2. Acceptance of standard terms and conditions and conduct of business

7.3.2.1. You accept that the policy will not commence and no liability thereunder will attach to or be attributable to us until we have activated your policy, you have received your policy schedule, and we have notified you in writing of the effective date from when we have accepted risk.

7.3.2.2. You know and understand we are not obliged to accept this application and may refuse to accept risk if we deem any person insured under the policies to be of a high or unacceptable risk, or we may accept it subject to conditions.

7.3.2.3. On acceptance of risk we will send you and your financial adviser (if applicable) a copy of the policy schedule and policy guide.

7.3.3. Confirmation of contract terms and 31 day cooling off period

7.3.3.1. You may object in writing within 31 days from the date the policy has been issued by us if you are not satisfied with any aspect or term thereof. If you do not object within this time it means that you have accepted the terms of the policy. You agree that this application form, any amendments or adjustments to the policy, the policy schedule and any plan guide that we issue in respect of the policy will form the policy contract. Provided that claims have not been paid and if you object within the 31-day period then the policy will be immediately cancelled and any premiums will be refunded to you.

7.3.4. Licenses and authorities

7.3.4.1. We hold professional indemnity and fidelity insurance cover as required by the Financial Advisory and Intermediary Services Act, 2002 (FAIS Act). 7.3.4.2. In terms of agreements entered into between Discovery Health (Proprietary) Limited and Discovery Life Limited, it has been agreed that Discovery

Health (Proprietary) limited shall on behalf of Discovery Life Limited provide underwriting, claims assessment, premium collection, policy renewal and general administration services in respect of the policy.

7.3.5. Privacy Statement (How we will process and disclose your personal information and communicate with you)

7.3.5.1. When you engage with us, you trust us with personal information about yourself, your dependants, and in some cases, your employees. We are committed to protecting your right to privacy. The purpose of this Privacy Statement is to set out how we collect, use, share and otherwise process your personal information, in line with the Protection of Personal Information Act (“POPIA”).

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7.3.5.2. You have the right to object to the processing of your personal information and have a choice whether or not to accept these terms and conditions. However, it is important to note that we require your acceptance to activate and service your policy. If you do not accept these terms and conditions, we cannot activate and service your policy.

7.3.5.3. You agree that we may process your personal information for the following purposes: facilitate the assessment of risk and underwrite the policy; and

• consider any claim under the policy made by you or any life assured or other person covered under the policy; and

• administrate the policy; and

• collect premiums; and

• profile and analyse your policy and conduct academic or product research and design. 7.3.5.4. We will keep your personal information confidential. You may have given us this information yourself or we may have collected it from other

sources. If you share your personal information with any third parties, we will not be responsible for any loss suffered by you, your dependants, and in some cases, your employees (where applicable).

7.3.5.5. You understand that when you include your dependants, and in some cases your employees, we will process their personal information for the activation of the policy and to pursue their legitimate interest. We will furthermore process their information for the purposes set out in this Privacy Statement.

7.3.5.6. If you are an employer, you agree to indemnify thus against any loss or damage, direct or indirect, that an employee suffers because of any unauthorised use of your employees' personal information.

7.3.5.7. If you are giving consent for a child you confirm that you are a competent person and that you have authority to give their consent for them. 7.3.5.8. You agree that we may process your personal information for the following purposes:

• To assist with the risk management and administration of your policy and for the consideration of any claims for benefits under this policy, you agree to the following terms and conditions:

• You hereby consent to the collection, collation, processing, storage and disclosure of the information, including Your Personal Information, contained in all sections of this application form for the purpose of risk management, administering this policy and for the assessment of any claims under this policy.

• For providing relevant information to a contracted third party who requires this information for the administration of your policy and benefits you are entitled to.

• To profile and analyse risk. 7.3.5.9. We may process your information using automated means (without human intervention in the decision making process) to make a decision about

you or your application for any product or service. You may query the decision made about you. 7.3.5.10. If a third party asks us for any of your personal information, we will share it with them only if:

• you have already given your consent for the disclosure of this information to that third party; or

• we have a legal or contractual duty to give the information to that third party including other insurers and re-insurers. 7.3.5.11 This information could be sourced either directly or through a database operated by or for insurers as a group, at any time. Such information could

be detailed, abbreviated or in a coded form and includes sharing of information on Industry Registers, such as the SAIA, Astute and ASISA. We will provide your personal information to any other entity within the Discovery Group with whom you or your dependant/s already have a relationship; or where you or your dependant/s have applied for a product, service or benefit from such entity. This information will be provided for the administration of your or your dependant/s products or benefits with other entities within the Discovery Group.

7.3.5.12 We may share and combine all the personal information that we have about you, your dependants and in some cases your employees for any one or more of the following purposes:

• market, statistical and academic research; and

• to customise our benefits and services to meet your needs. 7.3.5.13 Your personal information may be shared with third parties such as academics and researchers, including those outside South Africa. We ensure that

the academics and researchers will keep your personal information confidential and all data will be made anonymous to the extent possible and where appropriate. No personal information will be made available to a third party unless that third party has agreed to abide by strict confidentiality protocols that we require. If we publish the results of this research, you will not be identified by name.

7.3.5.14 If we want to share your personal information for any other reason, we will do so only with your permission. 7.3.5.15 By signing this application form, you authorise us to obtain and share information about your creditworthiness with any credit bureau or credit

providers’ industry association or industry body. This includes information about credit history, financial history, judgments, default history and sharing of information for purposes of risk analysis, tracing and any related purposes.

7.3.5.16 We have the right to communicate with you electronically about any changes on your policy including your premiums or changes and improvements to the benefits you are entitled to on your policy.

7.3.5.17 We have a duty to keep you updated about any offers and new products that are made available from time to time. We, any entity within the Discovery Group and contracted third-party service providers may communicate with you about these.

7.3.5.18 Please let us know if you do not wish to receive any direct telephonic marketing. 7.3.5.19 You have the right to know what personal information we hold about you. If you wish to receive this information please complete a complete the

‘Data Subject Request’ form on www.discovery.co.za and specify what information you would like. We will take all reasonable steps to confirm your identity before providing details of your personal information. We are entitled to charge a fee for this service and will let you know what it is at the time of your request. You agree that we may keep your personal information until you ask us to delete or destroy it. You have the right to ask us to update, correct or delete your personal information, unless the law requires us to keep it. Where we cannot delete your personal information, we will take all practical steps to de-personalise it.

7.3.5.20 Where we are required by law to collect and keep personal information, we shall do so. At a minimum, this includes the following

• The Financial Advisory and Intermediary Services Act, 2002;

• The Financial Intelligence Centre Act, 2002;

• The National Credit Act, 2005;

• The Long-term Insurance Act. 1998;

• The Short-Term Insurance Act, 1998;

• Medical Schemes Act, 1998;

• The Consumer Protection Act, 2008;

• The Protection of Personal Information Act, 2013;

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• Electronic Communications and Transactions Act, 2002; and

• Promotion of Access to Information Act, 2002. 7.3.5.21 You agree that the we may transfer your personal information outside South Africa:

• if you give us an email address that is hosted outside South Africa; or

• to administer certain services, for example, cloud services. 7.3.5.22 When we share your information to administer certain services, we will ensure that any country, company or person that we pass your personal

information to agrees to treat your information with the same level of protection as we are obliged to. 7.3.5.23 If we become involved in a proposed or actual amalgamation, transfer or merger, acquisition or any form of sale of any assets, as appropriate, we

have the right to share your personal information with third parties in connection with the transaction. In the case of such an event, the new entity will have access to your personal information. The terms of this Privacy Statement will continue to apply.

7.3.5.24 We may change this Privacy Statement at any time. The current version is available on www.discovery.co.za. 7.3.5.25 If you believe that we have used your personal information contrary to this Privacy Statement, you must first attempt to resolve any concerns with

us. If you are not satisfied after this process, you have the right to lodge a complaint with the Information Regulator, under POPIA. The contact details for the Information Regulator: The Information Regulator (South Africa) |SALU Building | 316 Thabo Sehume Street | PRETORIA | | Tel: 012 406 4818 | Fax: 086 500 3351 | [email protected]

7.4 Premiums 7.4.1 You agree to pay premiums for the policy on the date that they become due. You accordingly authorise us to collect due contributions and charges

from the bank account specified by you. 7.4.2 You undertake to advise us of any changes to these bank account details and you indemnify and hold us blameless for any damage that you or

anyone else may suffer as a result of your failure to notify us of this. 7.4.3 You understand that premiums in respect of the policy may be collected together with and from the same bank account from which your

contributions to the Medical Schemes administered by Discovery Health are deducted, or may be collected from a different bank account if specified. 7.4.4 If you do not pay premiums in respect of the policy when they become due or if we are unable to collect premiums in respect of the policy, the

following applies: 7.4.4.1 We will inform you that a premium has not been received. We will give you 30 days after the premium due date to make the payment. If you or any

person covered under the policy makes a claim during this period, we will consider a claim if you pay the outstanding premium; 7.4.4.2 If you do not pay a premium for the policy for a second consecutive month, in other words the policy is two premiums in arrears, we will inform

you of this and your policy will be cancelled and we will not consider any claims. 7.4.4.3 If someone other than you pays the premiums on your policy, you confirm that this arrangement is with the full knowledge and authority and on

behalf of that person. In addition, you give us permission to obtain any information relating to him or her from any one or more of the following, and warrant that you have authority to do so:

7.4.4.3.1 Any credit bureau; 7.4.4.3.2 Any life assurance or credit provider’s industry association; 7.4.4.3.3 Any other association of an industry in which we operate; 7.4.4.3.4 This includes information related to that premium payer’s creditworthiness, credit history, financial history, personal information, judgement

history and default history. It is your responsibility to verify the banking details of the premium payer on request, for example by giving us a cancelled cheque, a bank letter or a copy of a bank statement.

7.5 Intermediaries

7.5.1 You hereby give your financial adviser authority to deal with your policy on your behalf. 7.5.2 It may be that the financial adviser recorded by us in respect of your Scheme policy may be different to the financial adviser that advises or is

recorded in respect of this policy, being the policy for which you are now applying. You accordingly hereby give both financial advisers the authority to deal with both your Scheme and this policy on your behalf.

7.6 Cession

You may not cede your rights in terms of this policy to any other person.

8 Terms and conditions for Discovery Supplementary Gap Cover

8.1 Benefits

The details of the benefits under the Discovery Supplementary Gap Cover policy are more fully set out in the policy guide which is sent to you within 31 days of your policy being activated. You are reminded that this application form together with the policy schedule and policy guide form the basis of the contract, and that all documents must be collectively acknowledged as part of the policy contract.

8.2 Qualifying criteria 8.2.1 To qualify or apply for Discovery Supplementary Gap Cover you must be a member of the Scheme. (This does not include the KeyCare Plan or any

Scheme or plan that replaces or is equivalent to it, as these plans are not eligible for cover).

8.2.2 Only the main member on the Scheme may apply for this policy on his/her behalf, and on behalf of their spouse covered on the Scheme. 8.2.3 If you or your spouse are older than 60 years of age you or your spouse are not eligible for cover on the policy. 8.2.4 You, as the main member, and your spouse on the medical scheme plan will be insured on the Discovery Supplementary Gap Cover policy as the

principal life assured and spouse life assured unless your application as main member was rejected by our Underwriters or because you have passed the maximum entry age.

8.2.5 If your application (in your capacity of the main member of the medical scheme plan) has been rejected, you will be recorded as the non-assured entity owner on the policy. What this means is that you will not be entitled to enjoy any benefits under the policy. Your spouse however will be recorded as the assured lives entitled to receive benefits. Your spouse will be recorded as the principal life assured.

8.2.6 You or your spouse may not apply for a Discovery Supplementary Gap Cover policy if you or your spouse or both of you already have an existing Discovery Supplementary Gap Cover policy with us.

8.3 Exclusions 8.3.1 Any pre-existing condition is specifically excluded. A pre-existing condition is defined as any injury, illness or physical defect that arose prior to the

commencement or reinstatement dates of the policy that the principal, spouse or child suffered from, was aware of, or received medical treatment or advice for.

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8.3.2 Should you or any lives assured on this policy have a pre-existing medical condition at the time of applying for this policy, any claims related directly or indirectly to the treatment of this condition will be excluded from cover, commencing from the date of inception for the term of this policy.

8.4 If your circumstances change

8.4.1 You must tell us immediately about any factors that may affect the premiums you pay. If you do not give us this information immediately, we are entitled to adjust your premiums and we may refuse to pay a claim.

Smoking: You must tell us immediately if you started using tobacco (for example, smoking, chewing tobacco, snuffing, e-cigarettes etc.) if you are paying premiums as a non-smoker.

Hazardous activities: You and your spouse must tell us immediately if you are or intend to take part in any hazardous activities. Please refer to annexure 2 for a complete list of hazardous activities.

8.5 Premium details

8.5.1 Your premium for Discovery Supplementary Gap Cover will depend on your age, smoker status and the number of members on your medical scheme plan. Your spouse’s premium will depend on their age and smoking status. If your spouse is on a separate medical scheme plan, they will have to take out a separate Discovery Supplementary Gap Cover policy.

8.5.2 The total premium for Discovery Supplementary Gap Cover is the sum of your premium and the spouse premium (if applicable). 8.5.3 The Discovery Supplementary Gap Cover contribution will increase by a factor that will be in line with Scheme contribution increases and will also

take into account other experience factors on the Discovery Supplementary Gap product as well as an additional increase based on your age. We further reserve the right to adjust premiums if the terms or conditions of the policy were to change or if there are changes to your medical scheme plan.

8.6 Unclaimed benefits

8.6.1 It is your responsibility to keep your contact information up to date. If a benefit is unpaid because Discovery Life cannot contact you, your beneficiaries or dependants, using the contact details provided, we are required to contact a tracing company to trace you, your beneficiaries or dependants, after a prescribed period. You confirm that when you provide Discovery with personal information about any dependant or beneficiary in respect of this policy, they have given you permission to disclose that information to Discovery. This includes their permission to share their personal information with a tracing agent in order for them to help us trace you, your dependants or your beneficiaries. Please note that tracing fees will be deducted from the unclaimed benefit amount. This is subject to change over the policy term and will be communicated to you upon request. In the event that we are able to locate you, your beneficiaries or dependents and pay the claim, market-related interest will be added to the benefit from the date that the benefit became payable to date of payment.

8.7 Policy administration

8.7.1 We may obtain information about yourself, your dependants, and in some cases, your employees on the Scheme, from anyone, which could be any doctor or medical practitioner you have consulted with. You also authorise and instruct the person, with the information to give the information to us. We may share your health information with your financial adviser during any underwriting process. The consent given to obtain and share your health information continues after your death.

8.8 Where to complain Send your complaints to: [email protected]

9 Warranty

I hereby warrant, declare, confirm and acknowledge that: 9.1 I have read and understood the contents of this application form and agree to be bound by the terms and conditions of the application form, the policy

guide, the policy schedule, and any servicing alteration requests, which read together, form the policy contract. 9.2 Commissions have been explained to me by my appointed financial adviser. 9.3 To the extent that Discovery Group is not my appointed financial adviser, Discovery Group has not advised me, and as such are not responsible for any of

the choices I have made. 9.4 Discovery Group will not be responsible for any failure, malfunction or delay of any networks or electronic or mechanical device or any other form of

communication used in the submission, acceptance and processing of applications and transactions. 9.5 It is my responsibility to ensure that this application form, any instructions that are part of the application form and subsequent instructions submitted

electronically by fax or email to Discovery Group, have been received by Discovery Group. I acknowledge that Discovery Group does not consider a fax confirmation or printed copy of a sent email as proof of receiving the document or instruction.

9.6 I have disclosed all material information to Discovery Group. 9.7 If I breach the warranty contained in 7.3 above, Discovery Group can declare the benefits issued to me void and I will forfeit any contributions paid. 9.8 I as the main applicant agree that I am authorised and in a position to complete the medical questions on behalf of my spouse (if applicable).

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Annexure 2 – Hazardous Pursuits

List of hazardous activities*

Aviation – less than 100 hours per year and less than 100 hours flying experience Aviation - Aerobatics, Stunts, Exhibition flying, Air races Aviation - Crop Dusting Aviation - Fire Fighting Aviation - Hang Gliding Aviation - Microlighting Aviation - Parachuting Aviation - Paragliding Aviation - Sky surfing Aviation - Skydiving Aviation - Student Pilot Boxing - Amateur Game Spotting/Counting from the air. Game viewing for leisure is excluded Herpetologist Hunting - Big Game from the air Inflatable Boat Racing Mine Rescue Services Motor Sport - Marshal Motor Sport Racing - Hell driving Motorcycle racing - Drag Racing cat 1,2,3,4, & 5 Motorcycle racing - Super bikes Motorsport - Drag Racing - Cat 1, 1A, 2, 3 & 4 Motorsport - Formula GTI, -Ford, -Vee Motorsport - Hot Rods Mountaineering - Solo Climbing Mountaineering - Rope Climbing Powerboat Racing Rock Climbing - Solo Climbing Scuba Diving – deeper than 41m underwater Scuba Diving - Pot Holing/Caving Scuba Diving - Snorkeling deeper than 15 metres Skydiving - Exhibition events Water Ski Racing

Yacht Cruising - International

*The above is an exhaustive list.

gap cover supplementary form - discovery

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